Podcast 156 – The Central Line Show – Part I: Avoiding Complications and Confirmation

Read this Review of Vascular Complications of CVC Placement

When to Confirm

I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)

Confirming Venous Placement (Choose at least 1)

Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing

Determination of the of the intravascular pressure using sterile tubing as a venous manometer

Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)

Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.

Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)

Confirming the Subclavian went down instead of up

So Do We Need a Chest Radiograph?

I would say eventually, but certainly use the line way before the x-ray. And–Non-contrast radiographic examination should NOT be used to confirm that a central venous catheter is located in a vein. Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.

Do we need to turn off the Ventilator?

Influence of Mechanical Ventilation on the Incidence of Pneumothorax During Infraclavicular Subclavian Vein Catheterization: A Prospective Randomized Noninferiority Trial

For More on the Above, Please Read PulmCrit's Post on Central Line Positioning

Update: More Support for Ultrasound Confirmation (Emerg Med J doi:10.1136/emermed-2015-205000)

Treatment of Inadvertent Arterial Cannulation

‘If in doubt, don't take it out!' from the excellent review: [cite source='doi']10.1093/bja/aes497[/cite]

If there is a placement of a catheter into an artery, please follow the following procedures:

Introducer or Dialysis Catheter

1. Leave line in situ, clamp, and cap it
2. Call vascular consult
3. Vascular should not being pulling carotid introducer catheters in the ED, unless it is discussed with the vascular attending.
4. These patients usually need direct visualization of the injury in the OR or endovascular techniques

Triple Lumen

Go by local guidelines

Guilbert et al.'s series should explain why pull & pray may not be the best move [cite source='doi']10.1016/j.jvs.2008.04.046[/cite]

Injection of Meds into Unrecognized Arterial Lines

The article on arterial injection of medications was Mayo Clin Proc. 2005;80(6):783-795

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Cite this post as:

Scott Weingart. Podcast 156 – The Central Line Show – Part I: Avoiding Complications and Confirmation. EMCrit Blog. Published on August 29, 2015. Accessed on January 21st 2019. Available at [https://emcrit.org/emcrit/central-line-show/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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Gavin Ng

Hi Scott – Great podcast! Long time listener but first time commentor.

I am one of the ICU residents/ED registrars from a metropolitan hospital Down Under in Australia. Thank you for doing this fortnightly podcast! You’ve greatly contributed to my education so far.

My tip in order to avoid losing the guidewire from a central line: As soon as I withdraw the guidewire through the central line and the distal part of the guidewire comes through the brown port, I use an artery forceps to clamp down on the guidewire, thus securing it (and the guidewire can never be sucked in by any vascular gremlins any more). I find this works very well for me, and thankfully – have not lost any guidewires.

great stuff, Gavin. I will say, once the wire has popped out of the brown, you are already in the clear–you won’t lose your wire. Wires get lost because people do not push them all the way back through the line.

I just wanted to mention that there is a transduction probe which can be inserted through the back of the Raulerson syringe (using the same port the wire would go through). On the protruding end of the probe there is a luer lock which can be use for any of the methods you discussed in verifying placement. It basically creates an open pathway through the syringe & eliminates the need to remove the syringe from the insertion needle.

The probe is included in some of the more comprehensive Arrow CVC kits- which surprised me personally as the kit my ED used had this probe and no one really knew about it. It’s a nice little device that some may already have in their kits & not be aware of.

I use arrow and have the probe. Find the set-up unwieldy. Would love to see a 60 mm Hg non-electric, purely mechanical, strain gauge that pops up red between needle and syringe with a one-way valve

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3 years ago

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Joe Bellezzo

Such a mechanical valve (Turkey thermometer!) would be amazing.

What's Your Job?

Emergency Physician

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4 months ago

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Brian Pongracz

Great podcast Scott, I think this is an incredibly important topic as it is one of the most common ICU and ED procedures out there and the consequences can be devastating if you botch this procedure. I’ve seen horrible outcomes from very senior anesthesia providers cannulating the carotid pre-CV surgery and it was a sobering sight to behold. I am an Acute Care Nurse Practitioner and my practice in three different ICU’s over the years has always been to have a sterile pressure transducer ready to go before I start the line so the nurse can hand me the transducer and I can transduce my lines before sewing them in place. If you get a CVP waveform you know you are golden. In emergency situations the number one indication for these lines is pressor support, as PIV’s actually have much higher flow rates that a triple or quad lumen CVC. In those instances if I can see a CVP or even RV waveform I’m comfortable instilling norepi through that line, which presumably is the most dangerous agent aside from push dose epi. I like your idea of using the cannula over-the-needle as a first step and transducing that, as it… Read more »

I am an ED reg in Dublin. Just want to mention that one the most difficult bit I find is the dilatation. Especially with not dilating far enough, the cath then ends up kinking over the wire, some cases actually ripping the tip. But if going too far, end up causing lots of bleeding and further damage.

At times not enough local so the patient in pain so I hold back and not advance far enough..

Just wanna know whether you have any tricks regarding that. Is it the scapel nick, is it a twisting motion, push and how to gauge how far??

I know it’s off topic but it’s one of those things that is bugging me and I want to perfect the whole procedure.

Pun

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3 years ago

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Craig Rosebrock

Pun,

I find that the scalpel nick is important. If it is too small you can have issues with dilation.
I will also use a bit of a twisting motion when advancing the dilator. Another issue that you can run into is when the angle of entrance into the neck or groin is to abrupt. IE the dilator has to bend a bit to stay inline with the wire. I run into this more with those with a very large neck. The issue with subclavian dilation is that if the needle passed just barely pass the periostium of the bone, you can get hung up on the little bit of bone as the dilator is advanced. The other issue is developing a feel for the procedure. The more lines you do the more comfortable your tactile memory is for what feels too resistant vs what is just going to be a serious problem. I tend to not advance the dilator very far at all honestly.

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3 years ago

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Peter Korsten

Hi,

I am a Nephrology / rheumatology resident from Germany. I think that for triple lumen catheters the skin nick with the scalpel is not necessary if you are not in an emergent situation. Try to gently twist and push the dilator and it will go deeper eventually. You need a little patience for this but you might avoid some of those small bleeders from the incision site that take you like half an hour to stop.

– Peter

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3 years ago

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Craig Rosebrock

Great point Peter,

I find this to be a valuable alternative when a patient has a bleeding issue…ex from uremia, on blood thinners etc. When I teach residents and fellows, I urge the operator to use some dilation. I think that it allows for ease of placement and in larger necks, you might run into difficulty driving a catheter. I have seen numerous residents and even fellows struggle with placement of the catheter if they are trying to force a very flexible line to go through skin. Typically once the wire is in the vessel the hurdle of advancing over the wire is due to inadequate pathway dilation.

In kits such as dialysis catheters, there are usually two dilators. I find that you can usually get away with using just one.

I think that as one progresses through training and gets the feel of the line, then choosing not to dilate is the operator decision and based on the patient anatomy.

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3 years ago

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Nikolay Petrov

Hi Scott, awesome talk and great tips. I am cardiologist in Bulgaria with interest in pacemaker implantation (permanent and temporary). The method that I am using for verifying that I am in vein and not in artery (with approach from the IJ and SC) is to sink down the guidewire in the inferior vena cava before insertion of the catheter. This is very reliable method to confirm the venous access. There is no way to be in artery and the wire will pass below the diaphragm on the right side of the spine. Of course it`s a little bit confusing if there is persistent left superior vena cava. I know that it is not applicable in ED because you need fluoroscopy, but for me works great.
Sorry for my bad English.

We don’t have the pressure transducer set up where I work (large community ER near Seattle). My preferred technique is simply to have an IV set up hanging and ready. As soon as I have placed my line I attach it to the IV. If it’s arterial, the blood will back up the line quite a way, even in a hypotensive patient (60 mmHg=80cm H2O), even allowing for the resistance of the tubing. Obviously this is after dilation, but if I access the vessel and am worried that it might be arterial I can attach it to the hub of the needle using a sterile tubing extension before dilation. Seems easier than trying to dismantle the wire sheath one-handed while holding the needle in place.

Wish I had the pressure transducer though, it sounds like a nifty gadget. And I’m all about the gadgets.

Liam, Unfortunately this method will not work at all in the circumstances where differentiation is most critical and difficult.

Almost all infusion sets have built in anti-reflux valves to allow injection without having to pinch tubing. These can be seen as little disks on the line. I would be very surprised if your standard infusion sets did not have them. If you want to use the method you describe , you need blood tubing, which lacks these valves.

Even then, it is fraught with potential for misinterpretation in the setting of hypotension. An easy estimate of whether there will be backwards or forward flow is to halve the vessel pressure for height in inches of the IV bag. (J Clin Anesth Volume 2009;21(5):387) A normal-height hung IV bag will easily have forward flow into an artery. I can’t recommend this method of vessel confirmation.

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3 years ago

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Peter Korsten

HI Scott,

I really liked the post. Some thoughts: First, I think the Bubble test really obviates the need of for a CXR. Where else should the catheter be if not (somewhere) in the svc? It’s not even necessary for the exclusion of a pneumothorax, which can be excluded using ultrasound, as you mentioned.

How sure are you that the patient does not have a pneumothorax when you immediately scan the ipsilateral lung using ultrasound? Most pneumothoraces do not develop immediately with the exception of a tension pneumothorax.

How do you deal with ‘misplaced’ cvc personally? For example, if it goes from the IJ to the subclavia vein. Should be fine for meds. Using ultrasound, I corrected some ‘misplaced’ catheters by repositioning and scanning the subclavian vein and again performing the RASS.

– Peter

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3 years ago

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Craig Rosebrock

Keep hearing no chest x ray is needed. I argree that this is data supported but I have a few concerns. Have you guys not seen the IJ catheter go toward the skull before? My understanding is that the risk of thrombosis increases as the vessel lumen becomes smaller, so a caudal pathway may lead to venous thrombosis. Can this complication be discovered by anything other than CXR? If not what is the issue if any of infusion of epi, levo and the like toward the venous sinus? I dont get chest x rays in the ICU on my patient to check if the line is in the vessel. It is to check if the line has moved. I have had lines flip up toward the head on numerous patient over the years. Maybe there is no issue with this but I tend to feel that a bolus through such line is not optimal care. If somebody has data supporting the idea that it really does not matter WHERE the line is as long as its in a vein can you pass it along here. I do not get the CXR to see if the line is in a vein… Read more »

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3 years ago

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Craig Rosebrock

“I do not get the CXR to see if the line is in a vein at initial placement” needs to be clearer. I get a film but the reason is not to see if the line is in a vessel lumen its to see where the line is anatomically

sorry for the repost.. just forgot how to edit my post.

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3 years ago

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Peter Korsten

Hi Craig,

Getting a chest x-ray is still standard of care at my institution,too, to look for displaced catheters (especially those going cephalad). But with a negative flush test you already know that the line has been incorrectly placed or moved and you can correct it during the procedure and start scanning the vessels and find the cath. Sometimes this gets easier when you reintroduce the wire and scan subclavian, IJ, contralateral and so on.

– Peter

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3 years ago

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Craig Rosebrock

I am assuming that fluroscopy is not being used for placement mind you… as that is adequate, but I rarely see the fluro machine come out for a good ole fashion central line…..

I’m currently updating our local guideline in response to some complications. We’re emphasizing that it really should be a 2 person job (at least), where possible. The second person’s main role is to audit the process, in our case on a single page checklist that also serves as the procedure note. On it is standard stuff plus the IN/OUT check: this ensures that 2 people are convinced, by whichever method, that the line is IN the vein, and that the guidewire is OUT. Both sign the form and take responsibility.

Hi Scott! Long time listener first time commenter. I’m a first year EM Resident at Morristown Medical Center in Morristown, NJ. While listening to podcast 156, you discussed the only way to lose sight of the guidewire is to get interrupted by someone entering the room and asking a question. I know it may sound simple, but while I was on SICU my first month before any other part of prep was done for a CVC, we ALWAYS closed the door/curtains and used that STOP sign in the kits (instead of throwing them away like I’ve seen done in the past). Or, if we were doing any other procedure, we’d close the door/curtain and tie a clean biohazard bag to the handle or tape it to the wall outside the curtained door. At this point people knew to at least stop and knock or ask to come in (and give you the option to say no) before just barging inside. It worked pretty well.

Amen to the sharps!
There are definitively gremlins, but they don’t grab the wire during central lines–they drink my 3rd and 4th beers and then hit me in the head with a hammer while I am sleeping.

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3 years ago

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dave barounis

Scott, Thanks for posting, I think I will pass all my residents to this podcast before coming to the unit with me. A few things, do you really do confirm most of your central lines before dilation? I gown up with residents and after they get flash and pass wire successfully I look in longitudinal and short axis view at the entry point, and as far distally as my sterile field will go. In the neck or subclavian this is pretty easy, and if the resident back-walled the vessel its ALMOST ALWAYS at the site of puncture, which makes it much easier to pick up on long axis. I also have not needed to teach residents the catheter over technique for the following reasons: 1. The probe gets clamped with a kelly as it comes off the sterile drape towards the ultrasound device. It is not in the sterile field, and prevents it from slipping, so that becomes a non-issue. 2. If you pull the plunger out of the needle before starting and draw back on the plunger it makes removal and creation of negative pressure much easier (prevents difficulty taking plunger off). 3. If you have problems threading you… Read more »

Great episode Scott! I’ve gotten to demonstrate a number of these techniques at the bedside to the SICU and ED residents…they love em.

Just wanted to see if you’d seen the 3SITES study just published in NEJM that prospectively confirmed the old biases of central line infection (Subclavian cleanest, IJ=Femoral for infection rates, IJ/Fem have higher thrombosis rates than SC). I’d be interested in seeing what your take is given podcast 80…

[…] In terms of other microskills to placing a central line – I highly recommend the series of videos the Scott Weingart produced a few years ago. It is strange that we never actually teach, or get taught these simple tricks / hacks. Certainly, I was never instructed how to “rack n pull” or “dilate and twist” Check out the videos HERE […]